Conflicting Interest Certification For Proprietary Schools Only

VA Department of Veterans Affairs

CONFLICTING INTEREST CERTIFICATION FOR PROPRIETARY SCHOOLS ONLY

NAME AND ADDRESS OF INSTITUTION

PURPOSE: This form informs individuals that the law has restrictions concerning any potential conflict of interests. (See certifications (1) and (2) below). These certifications not only apply to chapters 31 and 36 of Title 38, U.S.C., buy also apply to the following programs administered by the Department of Veterans Affairs (VA):

MGIB Montgomery GI Bill-Active Duty Educational Assistance Program (Chapter 30 of Title 38, U.S. Code)

VEAP Veterans' Educational Assistance (Chapter 35 of Title 38, U.S. Code)

DEA Dependents' Educational Assistance (Chapter 35 of Title 38, U.S. Code)

MGIB-SR Montgomery GI Bill-Selected Reserve Educational Assistance Program (Chapter 1606, formerly known as Chapter 106, of Title 10, U.S. Code)

EAPP Educational Assistance Pilot Program (Section 903 of Public Law 96-342)

(1) PROPRIETARY PROFIT SCHOOLS ONLY The law prohibits employees of the Veterans Affairs (VA) and the State Approving Agency (SAA) from owning any interest in an educational institution operated for profit. In addition, the law prohibits these employees from receiving any wages, salary, dividends, gifts or services from private profit schools. These provisions may be waived if the VA determines that no detriment will result to the government or to veterans and eligible persons enrolled (38 U.S.C. 3683). Please list below those VA and SAA employees known by you who may have a potential conflict of interest under this provision. If there are none, please enter the word “none.”

NAME AND TITLE OF EMPLOYEE(S) DESCRIPTION OF ASSOCIATION WITH SCHOOL

(2) ALL PROPRIETARY SCHOOLS 38 CFR 21.4202(c) prohibits the approval of any veteran or eligible person in any proprietary school of which the veteran or trainee is an official authorized to sign certificates of enrollment or verification/certifications of attendance, an owner or an officer. Please list below the names and VA file numbers (claim or Social Security Numbers) of any certifying officials, owners or officers of your school who receive VA education assistance based on enrollment in your school. If there are none, please enter the word “none.” NAME AND TITLE OF EMPLOYEE(S) VA FILE NUMBER DATES OF ENROLLMENT WITH YOUR SCHOOL FROM TO

I DO HEREBY CERTIFY that the entries above are true and correct to the best of my knowledge. I agree to immediately notify the VA of any potential violations of the above prohibitions.

SIGNATURE OF PRESIDENT OR CHIEF ADMINISTRATIVE OFFICIAL OF SCHOOL TITLE DATE

VA FORM 22-1919 EXISTING STOCKS OF VA FORM 22-1919, MAY 1991, JUL 1995 WILL BE USED